Journal of Clinical and Aesthetic Dermatology

MAY 2018

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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E55 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY April 2018 • Volume 11 • Number 4 T H E E M E R G E N C Y K I T A n A e s t h e t i c Co m p l i ca t i o n s E x p e r t G ro u p Co n s e n s u s Pa p e r this recommendation is controversial as it might not be possible to get flashback into a syringe through fine needles with thick gels. In addition, the small size and collapsibility of facial vessels limit the efficacy. 6. Use a small-diameter needle. 1,7 A smaller needle necessitates slower injection and is less likely to occlude the vessel. If a sharp needle is being used, a perpendicular injection directly in contact with the bone is recommended; injecting into a deeper plane might avoid vessels. 7 7. Smaller syringes 4 are preferred to larger ones as a large syringe can make it more challenging to control the volume and increases the probability of injecting a larger bolus. 8. Consider using a cannula (minimum size 25G), as it is less likely to pierce a blood vessel. 1,7 Some authors recommend using the cannula in the medial cheek, tear trough, and nasolabial fold. 9. Use extreme caution when injecting a patient who has undergone trauma or a previous surgical procedure in the area. 4 10. Ensure that you are adequately trained, are using an appropriate product, are competent in treating the area you will be injecting, and are competent in the management of complications. 11. A technique to possibly prevent embolism of filler is digital compression of the inferior- medial orbital rim and the side of the nose 7 while injecting. Sometimes the ophthalmic artery does not arise normally from the internal carotid artery, but from the middle meningeal artery, which originates from the external carotid artery. Furthermore, the zygomatic-orbital artery raised from the superficial temporal artery has an anastomosis with branches of the ophthalmic artery, and might be a retrograde arterial embolic route. 14 Facial anatomy can be diverse; the facial artery originated from a single arterial trunk in 86 percent of specimens, and branching patterns were only symmetrical in 53 percent of cases. 16 In conclusion, there is no absolute safe area of the face to inject. 1 TREATMENT OF BLINDNESS AFTER FACIAL INJECTION Once the retinal artery has been occluded, there is a window of 60 to 90 minutes before blindness is irreversible. 7 It is advisable to transfer the patient to the nearest hospital with an eye specialist via blue light ambulance as quickly as possible. 4 Transfer to a non-specialist emergency department might lead to inordinate delay and worse outcome. 7 Ensure that you know where the closest hospital witih an eye specialist team is, and contact the on-call team as soon as possible to inform them of the situation. Provide the medical staff as much information as possible about the product, where it was injected, and the volume of injection used. Although there is no generally agreed-upon treatment regimen, 17 there are actions that can help. Prado 18 suggests a six-step therapy protocol with a "blindness safety kit" that can be used in a clinical setting and then continued into hospital. The protocol was adapted from Lazzeri et al. 1 TREATMENT ALGORITHM FOR OCULAR PAIN AND BLINDNESS AFTER FACIAL FILLERS Indications for treatment are sudden onset ocular pain and/or loss of vision. The goal is to quickly reduce the intraocular pressure to allow for the emboli to dislodge downstream and improve retinal perfusion. 1 Treatment must start within 90 minutes. • Stop treatment immediately. • Place patient in supine position. 7 • Call emergency medical service and prepare to transfer patient to hospital setting as soon as possible. DO NOT LET ANY OF THE BELOW DELAY REFERRAL TO A SPECIALIST EYE HOSPITAL. Reduce intraocular pressure. Administer Timolol 4,7 0.5% 1 to 2 drops in the affected eye only. This beta-adrenergic antagonist will aim to reduce intraocular pressure by reducing aqueous humor production. The patient should be encouraged to "rebreathe" in a paper bag to increase CO 2 levels within the blood, which will cause retinal arteries to vasodilate and could help dislodge blockage. An alternative to rebreathing through a paper bag is the inhalation of carbogen (95% O 2 , 5% CO 2 ). 4 Oral acetazolamide 4,7,14 may be considered, although intravenous administration in a hospital is likely to be of greater benefit. Give the patient 300mg of aspirin to prevent blood clotting. 14 Dislodge the embolus to a more peripheral position. Massage the globe with repeated increasing pressure. Prolonged ocular massage can dislodge emboli by rapidly changing intraocular pressure, 4 thereby changing the pressure and flow in the retinal arteries. Increasing the intraocular pressure also causes a reflexive dilation of the retinal arterioles, and dropping it suddenly increases the volume of flow significantly. Ocular massage is performed with the patient looking straight ahead with eyes closed. Gentle pressure is applied over the sclera with a finger, indenting the globe by a few millimetres and then releasing at a frequency of 2 to 3 times a second. 19 This should be continued until advised otherwise by staff at the eye hospital. Commonly, firm ocular massage is advised for several seconds and repeated only a few times. The alternative advice originates from two case studies where embolised retinal arteries were directly visualised during the massage process. This showed that even when the emboli were dislodged, more would occlude the vessel when massage stopped. Prolonged high frequency massage (up to three hours) had a better clearing effect. 19 Administer hyaluronidase. If hyaluronic acid has been used, administer hyaluronidase to the treatment area according to ACE Group Guideline "The Use of Hyaluronidase in Aesthetic Practice." Retrobulbar injection of hyaluronidase has been advocated by many plastic surgeons as emergency treatment; however, an evaluation by Zhu et al 3 failed to show any improvement in visual loss following 1500 to 3000 units of hyaluronidase injected into the retrobulbar space in four patients. Consensus from ophthalmologists is that retrobulbar hyaluronidase injections are technically difficult procedures even to a competent ophthalmological surgeon, and the scope for causing more harm by an aesthetic dermatology not very skilled at the procedure means the risks outweigh any benefit. However, Chestnut 20 recently reported in Dermatologic Surgery achieving full restoration of vision in a patient who received hyaluronic acid fillers in the midface. Vision was restored following three retrobulbar hyaluronidase injections and aspirin. A total of 750 units were administered, 450 units as retrobulbar injections and 300 units to surround the supraorbital and infraorbital foramina. Retrobulbar injections should only be considered by practitioners competent in this procedure in a specialist eye unit. Injection of hyaluronidase into the supratrochlear or supraorbital arteries to reach the embolus seems a more sensible approach. The use of

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